Quality demands risk management

Quality was a central theme at the 2006 Radiological Society of North America meeting in Chicago. American Board of Radiology director Dr. Robert Hattery urged delegates at the end-November meeting to make a lifelong commitment to professionalism and do what's right for patients. Prof. Gerald D. Dodd III, chair of radiology at the University of Texas Health Science Center at San Antonio, identified quality as a key differentiator in our professions.

Dr. Stephen Swensen, chair of radiology at the Mayo Clinic in Rochester, Minnesota, highlighted the importance of quality.

"Whether you are a small group or a huge multispecialty group practice, talking about quality is a really positive thing for healthcare professionals," Swensen said.

Dr. Brent C. James, vice president for medical research and continuing medical education at Intermountain Healthcare in Salt Lake City, Utah, continued the theme.

"Properly organized as a team, the best way to succeed financially is to improve your care to your patients," he said.

Anyone with several years' experience in radiology will be well aware of the many potential pitfalls that can occur during a medical imaging examination. These will have a bearing on the establishment and maintenance of a quality service.

A radiology examination can be divided into five subprocesses: appointment, registration, examination, reporting, and results distribution.

Several incidents remain fixed in my mind from my time as clinical operations manager of a large private radiology practice in Australia, where I was responsible for risk management and for public and professional indemnity. One of the most disturbing examples was the mishandling and transposition of two consecutive mammography examinations in a busy radiology reporting room. This resulted in a 70-year-old woman being reported as having breast cancer, while a 45-year-old patient was reported as normal. This incident had the potential to occur on a daily basis.

These films had been placed with incorrect film packets and referrals. The error was only discovered when the family of the older patient noticed a different name on the films. My role was to contact the referring doctor of the younger patient to advise him that the negative report was incorrect, a communication that resulted in understandable distress and subsequent anger. I also had to explain how such an error could occur and to assure him that the films had now been identified correctly. This was not an easy task.

Was this error avoidable? Absolutely. Was it likely to occur again? Most probably, unless steps were taken to change current work practices. Has such an error ever happened in your department? Would you be aware of it if it had? I'm sure we can all identify similar examples.

MOMENTS OF TRUTH

All five steps of the imaging process should be considered a potential source of risk.

An incorrect assumption or transfer of incorrect information when an appointment is being made can lead to an inappropriate examination. The patient may, for example, make a booking for a chest x-ray when the referring doctor actually requested a chest CT. We should not assume that patients will know the difference between the two x-ray-based examinations.

We are all aware of cases in which the wrong patient was collected from a waiting room, and subsequently underwent an incorrect examination. Further checks should be carried out to confirm identity when patients respond to a name being called by a nurse or technologist. This additional verification is essential if the patient is to undergo an interventional procedure or receive contrast.

It may seem obvious following an examination that the films or images match the clinical information. Again, this should not be assumed. Images are mislabeled more frequently than we might expect. Radiologists are taught to check the patient's name on films prior to reporting, but they should also be aware of images that may not match the patient's age or sex, for example. Breast images of a 40-year-old woman should differ from those of a 70-year-old woman.

We should also ensure that films relate to the correct referring physician. Is that actually the correct Dr. Smith or Dr. Lee? Are there several physicians of that name? It is not only frustrating when a patient's images and reports are sent to the wrong referrer, but it can also lead to a potentially life-threatening situation if the doctor does not return them or advise of the error. This can even result in unnecessary repeat examinations.

Measuring the likelihood of any of the above against the potential outcome is always a sobering exercise. Outcomes should take into account the full range of implications, whether financial, legal, or clinical. Take, for example, the case of a misdiagnosis that leads to a patient fatality and results in a high-profile lawsuit. Not only will this have a direct financial implication if the complainant is successful, but the subsequent media attention may damage a practice's reputation and result in significant loss of income. A similar situation could arise if lack of care caused a patient to gain a physical injury, whether from the radiological procedure itself or during transport to or from the examination room in a wheelchair or on a trolley.

RISK IDENTIFICATION

A risk identification exercise is a worthwhile way of minimizing risk within a hospital radiology department or private imaging practice. This exercise should ideally include representatives of all department stakeholder groups such as booking clerks and reception staff, technologists from different modalities, nursing staff, and radiologists.

All groups should rate each identified risk against a risk matrix, that is, likelihood versus consequence. We know, for example, that the likelihood of an adverse reaction to contrast is low, but the potential consequence can be catastrophic (see table).

Groups should also identify the range of consequences by considering specific examples and any existing history the department or clinic might have. Professional indemnity insurers are an excellent source of previous examples.

Once a potential risk has been identified and the consequences noted, the group should be asked to identify steps to minimize that risk. These could include:

• asking patients referred for contrast studies if they have any previous history of contrast or other allergy or suffer from asthma;

• observing and physically restraining patients left in wheelchairs or on trolleys; and

• using two-part stickers, one part being placed on the request form and the matching part being placed on a patient's identity bracelet.

The physical environment occupied by patients and staff should also be the subject of regular risk identification review. Are the waiting and examination room chairs safe and in good repair? Are the typists' and reporting radiologists' chairs safe and in good repair? Are the floors safe, with no worn carpets or slippery areas? Do all the ancillary electrical cords and devices comply with appropriate standards?

Conducting such a comprehensive review should assist with any quality accreditation process. It may also enable departments or imaging centers to negotiate discounts for professional indemnity and public liability insurance.

Staff members appreciate the opportunity to participate in a program directed at quality and excellence that ensures that they work in a safe, caring environment. Inviting all staff to contribute to a risk register will boost morale, provided that positive steps are taken to minimize any identified risks.

In addition to the identification, categorization, and minimization of risks, a process of incident and accident management is required as well. Should an adverse incident or accident occur, part of the management process should include matching the occurrence to the risk register. Comparing what actually happened with what should have taken place will highlight any differences in work practice.

Were all steps that had been identified to minimize the risk occurring carried out? If not, why not? If they were and an incident still occurred, what additional steps should now be added to the risk register? Risk identification, risk management, and incident review make up an ongoing and evolving process.

We should always remember that if it can happen, it probably will.

FURTHER READING

Canadian Journal of Medical Radiation Technology. Series of publications dealing with issues of patient safety. For more details, visit www.camrt.ca

Clinton HR, Obama B. Making patient safety the centerpiece of Medical Liability Reform. NEJM 2006;354:2205-2208.

Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007.

U.K. Royal College of Radiologists. Risk management in clinical radiology. London: BFCR 2002;2.

Mr. George is president of the International Society of Radiographers and Radiological Technologists (www.isrrt.org). He qualified as a diagnostic radiographer and was formerly a manager in a large private radiology practice in Adelaide, Australia. He is working with colleagues to produce open platform software that will integrate with RIS and HIS software to assist in risk identification and management processes, and link with national and international standards.